Appeals, allowable charge appeal and claims reconsideration

Quick links:

Medical necessity (prior authorization and claim) and non-covered services appeals definition instructions 

The appeal process is only applicable to charges denied as not covered or not medically necessary and are only accepted from appropriate appealing parties. A proper appealing party is:

  • The patient, any age.
  • The parent or guardian of a patient under age 18 (except sensitive diagnosis claims).
  • The patient may appoint a representative.

Note: A completed Appointment of Appeal Representative (AOR) form must be submitted with the appeal request. Appointed representatives MAY include:

  • Network providers; but, network providers cannot appeal without an AOR specific to the appeal being requested.
  • The legal representative of the estate of a deceased beneficiary.
  • An attorney acting on behalf of an otherwise proper appealing party listed above.

Who cannot appeal:

  • Congressional Appeal Offices
  • Non-participating providers - Does not agree to accept the TRICARE-allowable amount
  • Health Benefit Advisors (HBA)
  • Beneficiary Service Representatives (BSR)
  • Network providers (unless an AOR form is on file indicating beneficiary has given permission for the provider to act on his/her behalf)

Appeals submission: (Preferred method)

Fax: (877) 850-1046

Humana Military Appeals
PO Box 740044
Louisville, KY 40201-7444

Allowable charge review definition and instructions

Allowable charge appeal definition:
If a provider or a beneficiary has concerns about how a claim processed, an administrative review, also known as an allowable charge review, can be requested. It’s important to differentiate allowable charge reviews from medical necessity denial appeal requests.

Providers can submit a request for an administrative review when there are concerns about how a claim processed. The following are common reasons a provider may submit a request for administrative review: a request for administrative review, including:

  • Allowed amount disputes
  • Charges denied due to requested information not received
  • Coding issues
  • Cost-share and deductible issues
  • Eligibility denials
  • Other Health Insurance (OHI) issues
  • Penalties for no authorization
  • Third Party Liability (TPL) issues
  • Timely filing limit denials
  • Wrong procedure code

Allowable charge appeals are processed by WPS.

Allow charge submission:

Customer Service
TRICARE East Region
PO Box 8923
Madison, WI 53708-8923

Hours of operation: 8AM to 7PM ET

Phone: (800) 444-5445
Fax: (608) 221-7536

Claims reconsideration instructions

Claims reconsideration definition:
Participating providers may have claims reconsidered through medical review for issues including:

  • Requests for verification that the edit was appropriately entered for the claim
  • Situations in which the provider submits documentation substantiating unusual circumstances existed

Claims reconsideration submission:

Customer Service
TRICARE East Region
PO Box 8923
Madison, WI 53708-8923

Hours of operation: 8AM to 7PM ET

Phone: (800) 444-5445
Fax: (608) 221-7536